Perhaps the most important lesson that JHPIEGO has learned from more than 20 years of
field experience is that in order to have a lasting impact, projects cannot be isolated
events. Instead, they must be integrated into a larger framework. Integrated reproductive
health training may be seen as a network of pathways aimed at linking the national system
of higher education, the health care system, the political system and cultural norms to
strengthen reproductive health policy, training and services (Buffington 1995).
The Framework for Integrated Reproductive Health Training (see Figure 1) brings together the educational and
health systems of a country to focus on the preparation of a cadre of providers who can
deliver standardized, high quality services. Preservice and inservice training are
harmonized and coordinated in the model. Service delivery and clinical training are guided
by a single set of nationally accepted service guidelines that reflect up-to-date national
policy. Implementation of this model in various countries has demonstrated its
appropriateness and effectiveness in addressing reproductive health training and service
delivery needs.
As shown in this diagram, each element is linked to the others and while they can be
separated for illustrative purposes, in the end they are all part of the entire
reproductive health network. In this paper, an overview of the framework is
presented. It is organized along a continuum from needs assessment to the introduction of
trained service providers into service delivery points.
Figure 1. Framework for Integrated Reproductive Health Training
Before policy can be revised or national guidelines developed, the reproductive health
situation in a country has to be well understood and its needs defined. To do this, a
reproductive health sector needs assessment is performed. Policymakers and guidelines
developers use the results of this assessment when establishing or revising national
policy or guidelines. As part of this process, a training sector assessment is
carried out to identify service delivery needs that can be addressed through training.
This identifies gaps in the reproductive health training process and system.
Because training needs change as progress is made in expanding reproductive health
services, training needs should be reassessed periodically. To accommodate this, JHPIEGO
has developed prototypic tools that enable countries to conduct their own subsequent
assessments. In this way, countries can then redirect their resources where they are most
needed. The capacity to design and implement such assessments represents an important step
in sustainable development.
Accurate scientific information on reproductive health is essential to the development
of national policy and guidelines if a country wishes to maximize the quality of its
services and eliminate unneccessary barriers to their provision. In order to ensure that
guidelines reflect the most up-to-date scientific thinking on reproductive health, both
policymakers and guidelines developers need access to this information. Currently
published research reports and other publications (e.g., the JHPIEGO PocketGuide)
as well as reports on the deliberations of various scientific and technical working groups
(WHO and USAID) can be made immediately available through the use of modern information
technology such as the Internet. For example, JHPIEGO is beginning to provide this type of
information through its ReproLine® website as well as on CD-ROM.
National policy defines a government's strategy toward reproductive health: who
will receive services, which services will be provided, at what level of quality, through
which service delivery mechanisms, etc. Service guidelines are more technically
focused. They define who is eligible to receive each type of reproductive health service,
how each service is to be provided, what counseling should accompany each service,
indications and precautions for use of modern contraceptive methods, and management of
side effects and complications.
In the JHPIEGO model, the existence of reproductive health service guidelines is
essential for the entire system to function. Service guidelines serve several purposes.
For example, they help to:
- standardize the medical and technical components of reproductive health services,
regardless of where they are provided;
- establish norms for the client-provider interaction; and
- provide a reference for clinicians, trainers and administrators.
Inservice training ensures that health professionals already providing services
have the opportunity to update their knowledge and skills according to the latest
scientific information and standardized practices. Often, inservice training updates
knowledge rather than skills because clinical training sites are lacking. JHPIEGO's
interactive training approach calls for strengthening the inservice system so that it can
provide competency-based training, which transfers skills as well as knowledge and
attitudes (Sullivan 1995). JHPIEGO's approach also involves linking inservice training to
preservice training, especially for clinical skill development, whenever possible. This
linkage results in a systematic, coordinated training effort in which resources are
focused most effectively and development becomes more sustainable.
Preservice education and training involves those institutions that are concerned
with initial or basic training of health service providers at all levels (e.g., schools of
medicine, nursing, midwifery). In the JHPIEGO model, standardized training takes place at
sites shared by the ministries of health and education using nationally accepted service
guidelines. This allows for better coordination of training that is relevant to meet the
country's needs. Because preservice training generally is less disruptive to the service
delivery system, less expensive and more sustainable than inservice training, JHPIEGO
promotes a shift from inservice to preservice training wherever it is appropriate.
In the integrated reproductive health training model, clinical training for both the
preservice and inservice systems is offered at a single set of service and clinical
training sites. These sites are standardized as to essential equipment, supplies,
infection prevention practices and contraceptive services. Their clinical trainers start
out as service providers who with practice have become expert clinicians (physicians,
nurses and midwives). With additional training, they then acquire specific training skills
(e.g., coaching) in order to train to a common standard (see Figure 2). Thus the trainees from any of these
sites, whether they are medical interns, nursing students or practicing midwives, emerge
from training with the requisite knowledge and skills to competently provide a full range
of reproductive health services. The services these new clinicians deliver are provided in
the same way and at the same level of quality regardless of where they were trained. In
this way, clinical training sites link the preservice and inservice elements of the
reproductive health training system.
Figure 2. Faculty and Trainer Development
Pathway (click to view full size)
Service
Delivery Points
The reproductive health goal of most countries is to ensure the availability of high
quality reproductive health services to their populations. Trained clinical service
providers are essential to meeting this goal. Service delivery points are those
sites where trained clinical service providers work. These may be health stations in the
community, district health centers, district hospitals or provincial (referral) hospitals.
In the context of integrated training, when all of the other elements (e.g., logistics,
supply and effective management) are in place, having well-trained staff at all service
delivery points makes provision of quality reproductive health services possible on an
ongoing basis.
Regular feedback is needed to assess how well the integrated training system is
functioning. This feedback is provided through built-in evaluation mechanisms,
which often are informal. For instance, collection of routine data or even anecdotal
feedback from service delivery points may indicate changing client demands. In addition,
formal assessments, including special surveys, may be conducted to determine the impact of
changes in the way training or services are delivered. Data from both types of assessments
may indicate the need to develop a new inservice training course, to revise the preservice
curriculum, to change the service guidelines or to reconsider existing reproductive health
policy. In the JHPIEGO model, information generated at each point in the framework for
integrated reproductive health training can be shared with the other points in order
to make necessary adjustments and promote sustainable development.
Buffington S deCastro. 1995. A Framework for Establishing Integrated Reproductive
Health Training. Advances in Contraception 11: 317-324.
Sullivan RL et al. 1995. Clinical Training Skills for Reproductive Health
Professionals. Baltimore, Maryland. JHPIEGO Corporation.
Source: JHPIEGO Fact Sheet. March 97.
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